Combination therapy with Notch and PD-1 or PD-L1 inhibitors

ABSTRACT

The present invention provides medicaments for use in treating and methods of treating T-cell acute lymphoblastic leukemia, acute lymphoblastic leukemia, chronic lymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia, erythroleukemia, triple negative breast cancer, breast cancer, ovarian cancer, melanoma, Sung cancer, non small-cell lung cancer, pancreatic cancer, glioblastoma, colorectal cancer, head and neck cancer, cervical cancer, prostate cancer, liver cancer, oral squamous cell carcinoma, skin cancer, medulloblastoma, hepatocellular carcinoma, intrahepatic and extrahepatic cholangiocarcinoma, desmoid tumor, soft tissue sarcoma, or adenoid cystic carcinoma in a patient comprising combination therapy with 4,4,4-trifluoro-N-[(1S)-2˜[[(7S)-5-(2-hydroxyemyl)-6-oxo-7H-pyrido[23-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyljbutanamide, or a pharmaceutically acceptable salt or hydrate thereof, and a PD-1 or a PD-L1 inhibitor selected from pembrolizumab, nivolumab, atezolizumab, durvalumab, and avelumab.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a U.S. National Stage Application under 35 U.S.C. §371 of International Application No. PCT/US2017/032790, filedinternationally on May 16, 2017, which claims priority to and thebenefit of U.S. Provisional Application No. 62/339,363 filed May 20,2016, the entire contents of which are incorporated herein by referencein their entirety.

The present invention relates to cancer therapy with4,4,4-trifluoro-N-[(1S)-2-[[7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof (Compound A)and a Programmed Death Receptor 1 (PD-1) inhibitor, or a ProgrammedDeath Receptor Ligand 1 (PD-L1) inhibitor and to methods of usingcombinations to treat cancer.

4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methy-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, is a Notchpathway signaling inhibitor compound. Notch signaling plays an importantrole during development and tissue homeostasis. Dysregulation of Notchsignaling due to mutation, amplification, or overexpression of ligandsand/or receptors, is implicated in a number of malignancies. Inhibitionof Notch signaling is a potential target for the development of cancertherapeutics. Compound A and methods of making and using this compound,including for the treatment of T-cell acute lymphoblastic leukemia,acute lymphoblastic leukemia, acute myelogenous leukemia, chronicmyelogenous leukemia, erythroleukemia, breast cancer, ovarian cancer,melanoma, lung cancer, pancreatic cancer, glioblastoma, colorectalcancer, head and neck cancer, cervical cancer, prostate cancer, livercancer, squamous cell carcinoma (oral), skin cancer and medulloblastomaare disclosed in WO 2013/016081, and for treating leiomyosarcoma inPCT/US2016/026119. Compound A is being investigated in a phase 1clinical trial and expansion cohorts having a defined molecular pathwayalteration, or a tissue based malignant tumor, and in combination withother specifically identified anticancer agents against specified tumortypes showing mutations, amplification, or gene expression alterationsrelated to Notch pathway signaling, and in a clinical trial in patientswith T-cell acute lymphoblastic leukemia or T-cell lymphoblasticlymphoma (T-ALL/T-LBL).

Tumor cells escape detection and elimination by the immune systemthrough various mechanisms. Endogenously, immune checkpoint pathways areused in maintenance of self-tolerance and control of T cell activation.Binding of the PD-1 ligands, PD-L1 and PD-L2, to the PD-1 receptor foundon T cells, inhibits T cell proliferation and cytokine production.Upregulation of PD-1 ligands occurs in some tumors and signaling throughthis pathway contributes to inhibition of active T-cell immunesurveillance of tumors. Inhibition of PD-1 or PD-L1, has been shown torestore immune mediated destruction of tumors. Clinical research hasfound that targeting PD-1 or PD-L1 with antagonist antibodies releasesthe PD-1 pathway mediated inhibition of the immune response, includingthe anti-tumor response.

Notch pathway signaling is reported to be a regulator of PD-1 expressionby activated CD8⁺ T cells, Mathieu et al, Immunology and Cell Biology,2013, 91: 82-88, Despite existing treatment options for patients withcancer, there continues to be a need for new and different therapiesaffording one or both of enhanced efficacy and lower toxicity. Currentimmunotherapies have shown a benefit in a subset of cancer types andonly in a subset of patients. Novel therapies or combination strategiesare needed to improve the overall response against specific cancers orto facilitate extension of these treatments into cancers that maycurrently be less responsive to either agent alone.

It is believed the present invention provides beneficial therapeuticeffects from the combined activity of Compound A and anti-PD-1 or PD-L1monoclonal antibody inhibitor activity against T-cell acutelymphoblastic leukemia, acute lymphoblastic leukemia, chroniclymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenousleukemia, erythroleukemia, triple negative breast cancer, breast cancer,ovarian cancer, melanoma, lung cancer, non small-cell lung cancer,pancreatic cancer, glioblastoma, colorectal cancer, head and neckcancer, cervical cancer, prostate cancer, liver cancer, oral squamouscell carcinoma, skin cancer, medulloblastoma, hepatocellular carcinoma,intrahepatic and extrahepatic cholangiocarcinoma, desmoid tumors, softtissue sarcoma, and adenoid cystic carcinoma as compared to thetherapeutic effects provided by either agent alone.

One aspect of the present invention provides a method of treating T-cellacute lymphoblastic leukemia, acute lymphoblastic leukemia, chroniclymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenousleukemia, erythroleukemia, triple negative breast cancer, breast cancer,ovarian cancer, melanoma, lung cancer, non small cell lung cancer,pancreatic cancer, glioblastoma, colorectal cancer, head and neckcancer, cervical cancer, prostate cancer, liver cancer, oral squamouscell carcinoma, skin cancer, medulloblastoma, hepatocellular carcinoma,intrahepatic and extrahepatic cholangiocarcinoma, desmoid tumor, softtissue sarcoma, or adenoid cystic carcinoma in a patient comprisingadministering to a patient in need of treatment an effective amount of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, and aneffective amount of a PD-1 or PD-L1 inhibitor selected frompembrolizumab, nivolumab, atezolizumab, durvalumab, and avelumab.

A further aspect of the present invention provides a method of treatingcolorectal cancer in a patient, comprising administering to the patientin need of treatment an effective amount of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyridopyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, and aneffective amount of a PD-1 or PD-L1 inhibitor selected frompembrolizumab, nivolumab, atezolizumab, durvalumab, and avelumab.

Another aspect of the present invention provides a method of treatingT-cell acute lymphoblastic leukemia, acute lymphoblastic leukemia,chronic lymphoblastic leukemia, acute myelogenous leukemia, chronicmyelogenous leukemia, erythroleukemia, triple negative breast cancer,breast cancer, ovarian cancer, melanoma, lung cancer, non small celllung cancer, pancreatic cancer, glioblastoma, colorectal cancer, headand neck cancer, cervical cancer, prostate cancer, liver cancer, oralsquamous cell carcinoma, skin cancer, medulloblastoma, hepatocellularcarcinoma, intrahepatic and extrahepatic cholangiocarcinoma, desmoidtumor, soft tissue sarcoma, or adenoid cystic carcinoma in a patient,comprising administering to a patient in need of treatment,simultaneously, separately, or sequentially, an effective amount of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, and aneffective amount of a PD-1 or PD-L1 inhibitor selected frompembrolizumab, nivolumab, atezolizumab, durvalumab, and avelumab.Another aspect of the present invention provides a method of treatingcolorectal cancer in a patient, comprising administering to a patient inneed of treatment, simultaneously, separately, or sequentially, aneffective amount of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, and aneffective amount of a PD-1 or PD-L1 inhibitor selected frompembrolizumab, nivolumab, atezolizumab, durvalumab, and avelumab.

A further aspect of the present invention provides a compound4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof; and a PD-1 orPD-L1 inhibitor selected from pembrolizumab, nivolumab, atezolizumab,durvalumab, and avelumab; for simultaneous, separate, or sequential usein the treatment of T-cell acute lymphoblastic leukemia, acutelymphoblastic leukemia, chronic lymphoblastic leukemia, acutemyelogenous leukemia, chronic myelogenous leukemia, erythroleukemia,triple negative breast cancer, breast cancer, ovarian cancer, melanoma,lung cancer, non small cell lung cancer, pancreatic cancer,glioblastoma, colorectal cancer, head and neck cancer, cervical cancer,prostate cancer, liver cancer, oral squamous cell carcinoma, skincancer, medulloblastoma, hepatocellular carcinoma, intrahepatic andextrahepatic cholangiocarcinoma, desmoid tumor, soft tissue sarcoma, oradenoid cystic carcinoma.

Another aspect of the present invention provides a compound4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof; and a PD-1 orPD-L1 inhibitor selected from pembrolizumab, nivolumab, atezolizumab,durvalumab, and avelumab; for simultaneous, separate, or sequential usein the treatment of colorectal cancer.

A further aspect of the present invention provides: use of4,4,4-trifluoro-N-[(1S)-2[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof for themanufacture of a medicament; and use of a PD-1 or PD-L1 inhibitorselected from pembrolizumab, nivolumab, atezolizumab, durvalumab, andavelumab for the manufacture of a medicament; for the simultaneous,separate, or sequential treatment of T-cell acute lymphoblasticleukemia, acute lymphoblastic leukemia, chronic lymphoblastic leukemia,acute myelogenous leukemia, chronic myelogenous leukemia,erythroleukemia, triple negative breast cancer, breast cancer, ovariancancer, melanoma, lung cancer, non small cell lung cancer, pancreaticcancer, glioblastoma, colorectal cancer, head and neck cancer, cervicalcancer, prostate cancer, liver cancer, oral squamous cell carcinoma,skin cancer, medulloblastoma, hepatocellular carcinoma, intrahepatic andextrahepatic cholangiocarcinoma, desmoid tumor, soft tissue sarcoma, oradenoid cystic carcinoma.

A further aspect of the present invention provides: use of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof for themanufacture of a medicament; and use of a PD-1 or PD-L1 inhibitorselected from pembrolizumab, nivolumab, atezolizumab, durvalumab, andavelumab for the manufacture of a medicament; for the simultaneous,separate, or sequential treatment of colorectal cancer.

Another aspect of the present invention is a commercial packagecomprising a separate composition of each of the therapeutic agentstogether with instructions for simultaneous, separate or sequentialadministration for use in treating T-cell acute lymphoblastic leukemia,acute lymphoblastic leukemia, chronic lymphoblastic leukemia, acutemyelogenous leukemia, chronic myelogenous leukemia, erythroleukemia,triple negative breast cancer, breast cancer, ovarian cancer, melanoma,lung cancer, non small cell lung cancer, pancreatic cancer,glioblastoma, colorectal cancer, head and neck cancer, cervical cancer,prostate cancer, liver cancer, oral squamous cell carcinoma, skincancer, medulloblastoma, hepatocellular carcinoma, intrahepatic andextrahepatic cholangiocarcinoma, desmoid tumor, soft tissue sarcoma, oradenoid cystic carcinoma.

A still further aspect of the present invention is a commercial packagecomprising a separate composition of each of the therapeutic agentstogether with instructions for simultaneous, separate or sequentialadministration for use in treating colorectal cancer.

The compound4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, (Compound A)has the CAS registry number 142138-81-4. Alternatively, the compound maybe named:N-[(1S)-2-[[(7S)-6,7-dihydro-5-(2-hydroxyethyl)-6-oxo-5H-pyrido[3,2-a][3]benzazepin-7-yl]amino]-1-methyl-2-oxoethyl]-4,4,4-trifluorobutanamide.Other names may be used to unambiguously identify Compound A.

The terms, as used herein, “PD-1 inhibitor” and “PD-L1 inhibitor” mean afully human, or humanized IgG optionally optimized, monoclonal antibody.

PD-1 inhibitors include nivolumab and pembrolizumab. Nivolumah,(Opdivo®) also known as iMDX-1106, MDX-1106-04, ONO-4538, or BMS-936558and has a CAS Registry Number: of 946414-94-4. Nivolumab is a fullyhuman IgG4 monoclonal antibody which specifically blocks PD-1. Nivolumab(clone 5C4) and other human monoclonal antibodies that specifically bindto PD-1 are disclosed in U.S. Pat. No. 8,008,449 and WO2006/121168.Pembrolizumab, (Keytruda®) (formerly lambrolizumab), also known as Merck3745, MK-3475 or SCH-900475, is a humanized IgG4 monoclonal antibodythat binds to PD-1. Pembrolizumab is disclosed in Hamid, O. et al., NewEngland Journal of Medicine, 2013, 369(2): 134-44; WO2009/114335; andU.S. Pat. No. 8,354,509. Other anti-PD-1 antibodies are disclosed inU.S. Pat. No. 8,609,089; US 2010028330; and/or US 20120114649.

PD-L1 inhibitors include YW243.55.S70, MPDL3280A, MEDI-4736,MSB-0010718C, and MDX-1105. YW243.55.S70 is an anti-PD-L1 antibodydescribed in WO2010/077634 and US20100203056. MDPL3280A (also known asRG7446, RO5541267, atezolizumah, Tecentriq™) is a fully humanized Fcoptimized IgG1 monoclonal antibody that binds to PD-L1. MPDL3280A andother human monoclonal antibodies to PD-L1 are disclosed in U.S. Pat.No. 7,943,743 and US 20120039906. MEDI-4736 (also known as durvalumab)is an Fc optimized IgG1 monoclonal antibody to PD-L1 and is described inWO2011/066389. MSB-0010718C (also known as avelumab) is a fully humanIgG1 monoclonal antibody to PD-L1 and is described in WO2013/079174.MDX-1105, also known as BMS-936559, is a fully human IgG4 monoclonalanti-PD-L1 antibody described in WO2007/005874.

As used herein, the term “patient” refers to a mammal, preferably ahuman.

“Therapeutically effective amount” or “effective amount” means thedosage of Compound A, or pharmaceutically acceptable salt or hydratethereof, or pharmaceutical composition containing Compound A, orpharmaceutically acceptable salt or hydrate thereof, and the dosage of aPD-1 or PD)-L1 inhibitor, or pharmaceutical composition containing aPD-1 or PD-L1 inhibitor necessary to inhibit tumor cell growth andeliminate or slow or arrest the progression of the cancer in a patient.Dosages of Compound A, or a pharmaceutically acceptable salt or hydratethereof, are in the range of 2.5 mg/patient to 75 mg/patient once perday every other day over a five day period followed by two days withoutdosing (T.I.W.). Dosages of a PD-1 or PD-L1 inhibitor, unless otherwisespecified on the label, are in the range of 1-3 mg/kg intravenousinfusion over 30 to 60 minutes once every 14-21 days. Preferred dosagesof Compound A, or a pharmaceutically acceptable salt or hydrate thereof,are in the range of 10 mg to 50 mg T.I.W. The exact dosage required totreat a patient and the length of treatment time will be determined by aphysician in view of the stage and severity of the disease as well asthe specific needs and response of the individual patient. The dosingadministration may be adjusted to provide a more optimal therapeuticbenefit to a patient and to manage or ameliorate any drug relatedtoxicities. Alternative dosing schedules such as once per day (QD),twice per day (B.I.D.), three times a day (T.I.D.); dosing once per dayevery other day (Q2D); or every third day (Q3D) may be appropriate forCompound A. Dosing administration for PD-1 or PD-L1 inhibitors may beadjusted, including withholding a dose or permanently discontinuingfurther dosing to manage or ameliorate drug related toxicities.

A combination therapy of the present invention is carried out byadministering to a T-cell acute lymphoblastic leukemia, acutelymphoblastic leukemia, chronic lymphoblastic leukemia, acutemyelogenous leukemia, chronic myelogenous leukemia, erythroleukemia,triple negative breast cancer, breast cancer, ovarian cancer, melanoma,lung cancer, non small cell lung cancer, pancreatic cancer,glioblastoma, colorectal cancer, head and neck cancer, cervical cancer,prostate cancer, liver cancer, oral squamous cell carcinoma, skincancer, medulloblastoma, hepatocellular carcinoma, intrahepatic andextrahepatic cholangiocarcinoma, desmoid tumor, soft tissue sarcoma, andadenoid cystic carcinoma preferably a soft tissue sarcoma patientrequiring treatment, an effective amount of Compound A, or apharmaceutically acceptable salt or hydrate thereof, once per day everyother day over five days and two days without dosing each week (7-days)over a 28 day cycle and a PD-1 or PD-L1 inhibitor at 1-3 mg/kg over30-60 minutes once every 14-21 days.

The terms “treatment,” “treat,” and “treating,” are meant to include thefull spectrum of intervention for the cancer from which the patient issuffering, such as administration of Compound A and A PD-1 or PD-L1inhibitor to alleviate, slow, stop, or reverse one or more of thesymptoms and to delay, stop, or reverse progression of the cancer evenif the cancer is not actually eliminated.

Compound A or a pharmaceutically acceptable salt or hydrate thereof, ispreferably formulated as a pharmaceutical composition using apharmaceutically acceptable carrier and administered by a variety ofroutes. Preferably, such compositions are for oral administration. APD-1 or PD-L1 inhibitor is preferably formulated as a pharmaceuticalcomposition using a pharmaceutically acceptable carrier and administeredby a parenteral route, preferably intravenous infusion. Preferably, suchcompositions may be a lyophilized powder or a liquid composition.Reconstitution or dilution to ready for administration dosages areaccording to label or by routine skill in the art. Such pharmaceuticalcompositions and processes for preparing them are well known in the art.See, for example, HANDBOOK OF PHARMACEUTICAL EXCIPIENTS, 5^(th) edition,Rowe et al., Eds., Pharmaceutical Press (2006); and REMINGTON: THESCIENCE AND PRACTICE OF PHARMACY (Troy, et al., Eds., 21″ edition,Lippincott Williams & Wilkins (2006).

Compound A is capable of reaction with a number of inorganic and organiccounterions to form pharmaceutically acceptable salts. Suchpharmaceutically acceptable salts and common methodology for preparingthem are well known in the art. See, for example, P. Stahl, et al.,HANDBOOK OF PHARMACEUTICAL SALTS: PROPERTIES, SELECTION AND USE,(VCEA/Wiley-Val, 2002); S. M. Berge, et al., “Pharmaceutical Salts,”Journal of Pharmaceutical Sciences, Vol. 66, No. 1, January 1977.

The efficacy of the combination treatment of the invention can bemeasured by various endpoints commonly used in evaluating cancertreatments, including but not limited to, tumor regression, tumor weightor size shrinkage, time to progression, overall survival, progressionfree survival, overall response rate, duration of response, inhibitionof metatstatic spread without tumor regression, and PET/CT imaging.

The terms “combination,” “therapeutic combination” and “pharmaceuticalcombination” refer to a non-fixed dose combination, optionally packagedtogether with instructions for combined administration where theindividual therapeutic agents, Compound A, or a pharmaceuticallyacceptable salt or hydrate thereof, and a PD-1 or PD-L1 inhibitor may beadministered independently at the same time or separately within timeintervals that allow the therapeutic agents to exert a cooperativeeffect.

The term “simultaneous” administration means the administration of eachof Compound A and a PD-1 or PD-L1 inhibitor to a patient in a singleaction such as where each of Compound A and a PD-1 or PD-L1 inhibitorare administered independently at substantially the same time orseparately within time intervals that allow Compounds A and a PD-1 orPD-L1 inhibitor to show a cooperative therapeutic effect.

The term “separate” administration means the administration of each ofCompound A and a PD-1 or PD-L1 inhibitor to a patient from non-fixeddose dosage forms simultaneously, substantially concurrently, orsequentially in any order. There may, or may not, be a specified timeinterval for administration of each Compound A and a PD-1 or PD-L1inhibitor.

The term “sequential” administration means the administration of each ofCompound A and a PD-1 or PD-L1 inhibitor to a patient from non-fixed(separate) dosage forms in separate actions. The two administrationactions may, or may not, be linked by a specified time interval. Forexample, administering Compound A and administering a PD-1 or PD-L1inhibitor over a specified time such as once every 14 to 21 days.

The phrase “in combination with” includes the simultaneous, separate,and sequential administration of each of Compound A and a PD-1 or PD-L1inhibitor to a cancer patient in need of treatment, particularly acolorectal cancer patient.

The term “co-administration” or “combined administration” encompassesthe administration of the therapeutic agents to a single patient, andinclude treatment regimens in which the agents may be administered bydifferent routes of administration or at different times.

The beneficial action of two therapeutic agents producing an effect in asingle patient which is greater than the simple additive effects of eachagent administered alone may be calculated, for example, using suitablemethods known in the art such as the Sigmoid-Emax equation (Holford andScheiner, Clin. Pharmacokinet., 1981, 6: 429-453), the equation of Loeweadditivity (Loewe and Muischenk, Arch. Exp. Pathol. Pharmacol., 1926,114: 313-326), the median-effect equation (Chou and Talalay, Adv. EnzymeRegul., 1984, 22: 27-55), and the Bliss Independence method, or knownequivalents. Each equation may be applied to experimental data togenerate a corresponding graph to aid in assessing the effects of a drugcombination as additive, within a biologically relevant range ofadditive, less than additive, or greater than additive.

The oncogenic role of Notch was first reported in human T-cell leukemiainvolving a translocation of the Notch1 intracellular domain to theT-cell receptor-β promoter region, resulting in the over expression ofNotch1 intracellular domain (Grabher et al. Nature Review Cancer,2006(6):347-359; Weng et al. Science, 2004(306):269-271). Overexpression of Notch1 intracellular domain in hematopoietic progenitorcells of mice caused the mice to exhibit T-cell acute lymphoblasticleukemia similar to humans. In addition to T-cell acute lymphoblasticleukemia; there is increasing evidence that Notch signals are oncogenicin other cancers through multiple mechanisms including receptoramplification and over expression of ligands and/or receptors includingacute lymphoblastic leukemia, chronic lymphoblastic leukemia (Rosati etal, Blood, 2009(113): 856-865), acute myelogenous leukemia (Sliwa et al.Int J Clin Exp Pathol, 2014(7(3)): 882-889), chronic myelogenousleukemia (Nakahara et al. Blood, 2010(115(14)): 2872-2881), anderythroleukemia (Robert-Moreno et al, Leukemia, 2007(21): 1496-1503).Aberrant constitutive Notch signaling due to mutation or over expressionof ligands and/or receptors is also implicated in a number of solidtumor malignancies including triple negative breast cancer (Stoeck etal, Cancer Discovery, 2014(4): 1154-1167), breast cancer, ovarian cancer(Park et al. Cancer Research, 2006(66):6312-6318), melanoma (Gast et al.Genes, Chromosomes & Cancer, 2010(49):733-745), lung cancer, non smallcell lung cancer (Westhoff et al. PNAS, 2009(106):22293-22298),pancreatic cancer, glioblastoma, colorectal cancer, head and neckcancer, cervical cancer, prostate cancer, liver cancer, squamous cellcarcinoma (oral), skin cancer and medulloblastoma (Rangathan et al.,Nature Review Cancer, 2011(11):338-351 and Supplementary information S1(table)). Aberrant constitutive Notch signaling due to mutation or overexpression of ligands and/or receptors is also implicated inangiosarcoma (Ravi et al, J Clin Oncol, 2007, (25(18S, June 20Supplement)): Abstract 10030), rhabdomyosarcoma (Belyea et al, ClinCancer Res, 2011(17(23)): 7324-7336; Roma et al, Clin Cancer Res,2011(17(3)): 505-513), liposarcoma (J Clin Oncol, 2009, (27(15S,Supplement)): Abstract 10526), malignant fibrous histiocytoma (Wang etal, Cancer Res, 2012, (72): 1013-1022), hepatocellular carcinoma(Villanueva et al, Gastroenterology, 2012, (143): 1660-1669),intrahepatic and extrahepatic cholangiocarcinoma (Wu et al, Int J. ExpPathol, 2014, (7(6)): 3272-3279; Sekiya et al, J Clin Invest, 2012,(122(11)): 3914-3918; Yoon et al, World J Gastroenterol, 2011, (17(35)):4023-4030), and adenoid cystic carcinoma (Bell et al, Annals ofDiagnostic Pathology, 2014, (18): 10-13; Stoeck et al, Cancer Discov,2014, (4): 1154-1167).

The nature of cancer is multifactorial. Under appropriate circumstances,therapeutic agents with different mechanisms of action may be combined.However, only considering a combination of therapeutic agents havingdifferent modes of action does not necessarily lead to combinations withadvantageous effects. Specific therapeutic agents affording demonstratedbeneficial effects (therapeutic effect such as enhanced efficacy and/orlower toxicity) compared with monotherapy of only one of the therapeuticagents is preferred.

The combination of the present invention is believed suitable for thetreatment of T-cell acute lymphoblastic leukemia, acute lymphoblasticleukemia, chronic lymphoblastic leukemia, acute myelogenous leukemia,chronic myelogenous leukemia, erythroleukemia, triple negative breastcancer, breast cancer, ovarian cancer, melanoma, lung cancer, non smallcell lung cancer, pancreatic cancer, glioblastoma, colorectal cancer,head and neck cancer, cervical cancer, prostate cancer, liver cancer,oral squamous cell carcinoma, skin cancer, medulloblastoma,hepatocellular carcinoma, intrahepatic and extrahepaticcholangiocarcinoma, desmoid tumor, soft tissue sarcoma, and adenoidcystic carcinoma, and particularly suitable for the treatment of softtissue sarcoma patients, who have failed standard therapy. This includespatients having cancer showing resistance to monotherapy or showingresistance to combinations different from those of the presentinvention.

The terms “Complete Response” (CR), “Partial Response” (PR),“Progressive Disease” (PD), “Stable Disease” (SD), “Objective Response”(OR) are used consistent with definitions according to RECIST v1.1,Eisenhauer et al., European Journal of Cancer, 2009, 45, 228-247.

The term “time to disease progression” (TTP) refers to the time,generally measured in weeks or months, from the time of initialtreatment, until the cancer progresses (see RECIST v1.1 definition forprogressive disease) which is at least a 20% increase in the sum ofdiameters of target lesions, taking as reference the smallest sum onstudy (this includes the baseline sum if that is the smallest on study).In addition to the relative increase of 20%, the sum must alsodemonstrate an absolute increase of at least 5 mm. The appearance of oneor more new lesions is also considered progression. Such progression isevaluated by a skilled clinician.

The term “extending TTP” refers to increasing the time to diseaseprogression in a treated patient relative to i) an untreated patient, or11) a patient treated with less than both of Compound A and a PD-1 orPD-L1 inhibitor.

The term “survival” refers to the patient remaining alive, and includesoverall survival as well as progression free survival.

The term, “overall survival” refers to the patient remaining alive for adefined period of time, such as 1 year, 5 years, etc. from the time ofdiagnosis or treatment.

The term, “progression free survival” refers to the patient remainingalive, without the cancer progressing.

As used herein, the term “extending survival” is meant increasingoverall or progression free survival in a treated patient relative to i)an untreated patient, ii) a patient treated with less than both ofCompound A and a PD-1 or PD-L1 inhibitor, or iii) a control treatmentprotocol. Survival is monitored for a defined period of time, such asone month, six months, 1 year, 5 years, or 10 years, etc., following theinitiation of treatment or following the initial diagnosis of cancer.

The term “primary tumor” or “primary lesion” is meant the originalcancer and not a metastatic tumor or lesion located in another tissue,organ, or location in the patient's body.

In one embodiment, the dose of Compound A is escalated until the MaximumTolerated Dosage is reached, and a PD-1 or PD-L1 inhibitor of thepresent invention is administered with a fixed dose. Alternatively,Compound A may be administered in a fixed dose and the dose of a PD-1 orPD-L1 inhibitor may be escalated. Each patient may receive doses ofCompound A and/or a PD-1 or PD-L1 inhibitor either daily orintermittently. The efficacy of the treatment may be determined in suchstudies, e.g., after 12, 18 or 24 weeks by evaluation of symptom scoresevery 6 weeks.

Compound A may be prepared by the procedures described in WO2013/016081.

A PD-1 or PD-L1 inhibitor may be prepared by the procedures described inU.S. Pat. No. 8,008,449 and WO2006/121168; Hamid, O. et al., New EnglandJournal of Medicine, 2013, 369 (2): 134-44; WO2009/114335, and U.S. Pat.Nos. 8,354,509; 8,609,089, US 2010028330, and/or US 20120114649;WO2010/077634; US2010203056; U.S. Pat. No. 7,943,743; US 20120039906;WO20111066389; WO2013/079174; and WO2007/005874; or by procedures wellknown and routinely used by one skilled in the art.

The following Examples illustrate the activity of each of Compound Aalone, a PD-1 inhibitor alone, or a PD-L1 inhibitor alone, and thecombination of Compound A and a PD-1 or PD-L1 inhibitor.

BIOLOGICAL EXAMPLE 1

In-vivo Study:

For in-vivo studies 1×10⁶ CT26 cells (ATCC® CRL2639™) a colorectalcancer cell line, in 0.2 mL Hank's Balanced Salt Solution (HBSS) isimplanted by subcutaneous injection in the hind leg of 6-8 weeks of ageBALB/C female mice (Harlan Laboratories) Mice are fed ad libitum onnormal chow. Treatment is initiated on day 6 of tumor implantation withoral administration (gavage) of Compound A in 1% Sodium carboxymethylcellulose (Na-CMC) in 0.25% Tween® 80, or intraperitoneal injection ofmouse anti PD-L1 antibody (10F.9G2, BioXcell Catalogue #: BE0101) inphosphate buffered saline (PBS) or intraperitoneal injection of mouseanti PD-1 (CD279) antibody (Clone: RMP1-14, BioXCell #: BP0146-R) in PBSor their respective vehicle in 0.2 mL volume. Compound A is administeredat 8 mg/kg on a Monday, Wednesday and Friday schedule for 2 weeks and10F.9G2 and RMP1-14 are administered at 250 μg/dose/animal on Monday andThursday schedule for 2 weeks.

Tumor growth and body weight are monitored over time to evaluateefficacy and signs of toxicity. Bidimensional measurements of tumors areperformed twice a week and tumor volumes are calculated based on thefollowing formula: (Tumor Volume)=[(L)×(W2)×(Π/6)] where L is mid-axislength and W is mid-axis width. Tumor volume data are transformed to alog scale to equalize variance across time and treatment groups. The logvolume data are analyzed with a two-way repeated measures analysis ofvariance by time and treatment using the MIXED™ procedures in SAS™software (version 8.2). The correlation model for the repeated measuresis spatial power. Least squares means from the repeated measuresanalysis, anti-logged to the tumor volume scale, are shown in Table 1.P-values for comparing each pair of groups on study day 20 are shown inTable 2. Test Groups are:

-   1: 1% CMC/0.25° Tween® 80/0.05% Antifoam, Monday-Wednesday-Friday    ×2, PO/PBS Monday-Thursday ×2, IP-   2: Compound A, 8 mg/kg, Monday-Wednesday-Friday ×2, PO-   3: Compound B (PD-L1), 250 μg/dose, Monday-Thursday ×2, IP-   4: Compound C (PD-1), 250 μg/dose, Monday-Thursday ×2, IP-   5: Compound A, 8 mg/kg, Monday-Wednesday-Friday ×2, PO/Compound B    (PD-L1), 250 μg/dose, Monday-Thursday ×2, IP-   6: Compound A, 8 mg/kg, Monday-Wednesday-Friday ×2, POI Compound C    (PD-1), 250 μg/dose, Monday-Thursday ×2, IP

Tumor growth and body weight are monitored over time to evaluateefficacy and signs of toxicity. Bidimensional measurements of tumors areperformed twice a week and tumor volumes are calculated based on thefollowing formula: (Tumor Volume)=[(L)×(W2)×(Π/6)] where L is mid-axislength and W is mid-axis width. Tumor volume data are transformed to alog scale to equalize variance across time and treatment groups. The logvolume data are analyzed with a two-way repeated measures analysis ofvariance by time and treatment using the MIXED™ procedures in SAS™software (version 8.2). The correlation model for the repeated measuresis spatial power. Treated groups are compared to the control group ateach time point. The MIXED™ procedure is also used separately for eachtreatment group to calculate adjusted means and standard errors at eachtime point. Both analyses account for the autocorrelation within eachanimal and the loss of data that occurs when animals with large tumorsare removed from the study early. The adjusted means and standard errorsare plotted for each treatment group versus time. Antitumor activity isexpressed as a tumor volume percentage for treatment versus control (%TIC) and is calculated by comparing tumor volume in the treatment groupwith vehicle treatment group. Percentage T/C and statisticalsignificance value (p value) for the treatment groups is measuredessentially as described above and summarized in Table 2.

TABLE 1 Tumor volume (mm³): Geometric Mean Study Days Group 8 10 14 1720 1 52.92 99.25 486.99 1045.42 1643.20 Vehicle 2 47.96 88.80 376.50751.13 1227.40 Compound A 3 49.82 96.48 378.49 790.67 1313.36 Compound B4 45.30 87.73 241.50 491.72 622.56 Compound C 5 42.79 88.58 221.73321.19 472.83 Compound A + B 6 47.88 102.62 245.30 501.45 569.20Compound A + C

TABLE 2 Tumor volume all pairs comparison p value 2 3 4 5 Com- 6 Com-Com- Com- Com- pound pound Group pound A pound B pound C A + B A + C 10.26 0.362 <0.001 <0.001 <0.001 Vehicle 2 0.828 0.009 <0.001 0.001Compound A 3 0.005 <0.001 <0.001 Compound B 4 0.036 0.455 Compound C 50.17 Compound A + B

Table 2 shows the combination of Compound A and PD-L1 (Group 5), in thistest, demonstrated statistically significant tumor growth inhibitionresults over each of Compound A (Group 2) and PD-L1 alone (Group 3). Thecombination of Compound A and PD-1 (Group 6) demonstrated statisticallysignificant growth inhibition results over Compound A (Group 2) alone,but not over PD-1 (Group 4) alone.

Combination Analysis

Using the repeated measures analysis previously described, a contraststatement is used to test for an interaction effect on study day 20,using the two specific treatments (Compound A and PD-L1) that werecombined. This test is statistically significant with p=0.008,demonstrating better than additive, or synergistic activity, since theestimated mean tumor volume in the combination group (298 mm³) is lessthan the expected additive tumor volume per the Bliss Independencemethod (1134×1069/1448=837 mm³).

Using the repeated measures analysis previously described, a contraststatement is used to test for an interaction effect on study day 20,using the two specific treatments (Compound A and PD-1) that werecombined. This test is not statistically significant with p=0.769,demonstrating an additive effect, since the estimated mean tumor volumein the combination group (431 mm³) is close to the expected additivetumor volume per the Bliss Independence method (526×1069/1448=389 mm³).

Mechanism Analysis

For mechanism analysis CT-26 tumors are excised on day 20, 1h followingthe last dose of Compound A. A small piece of approximately 30 mg is cutand stored in RNALater for gene expression analysis. The remainder ofthe tumor is processed for the flow-cytometry analysis.

Flow-Cytometry

Tumors are weighed and then homogenized in 5 ml 4° C. complete media(CM; RPMI-1640/10% fetal bovine serum (FBS)) through 100 μm strainers toproduce single-cell suspensions. Cells are centrifuged for 5 minutes at466×g, 4° C.; the pellets are resuspended in fresh CM (0.5-3 ml,depending on pellet volume), and cells are counted using a Vi-Cell XR(Beckman Coulter). An equal number of total cells per tumor (10×10⁶) aretransferred to 96-well V-bottom microplates (Fisher Scientific). Cellsare centrifuged (700×g, 3 min., 4° C.) and resuspended in 100 μl 1 μg/mlFc block in CM (anti-CD16/32 (clone 2.4G2); Tonbo Biosciences) for 30minutes on ice. Cells are centrifuged (700×g, 3 minutes, 4° C.) andresuspended in 100 μl of one of several fluochrome-conjugated surfacemarker antibody cocktails [anti-CD3 (clone 145-2C11), -Ly-6G (clone1A8), -CD11c (clone HL3), -CD45 (clone 30-F11) (BD Biosciences),anti-CD8 (clone 53-6.7) (Biolegend), -CD11 b (clone M1/70), -CD3 (clone145-2C11), -F4/80 (clone BM8), -CD4 (clone RM4-5), (eBioscience)]containing a fixable viability dye (eBioscience) and incubated for 30minutes on ice covered from light. Cells are twice washed with 200 μl CMand centrifuged (700×g, 3 min., 4° C.). Following the second wash, cellsare fixed, permeabilized, and intracellularly stained for Ki67 (cloneSolA15) (eBioscience) using the Foxp3/Transcription Factor StainingBuffer Set (eBioscience), following the manufacturer's instructions withnoted modifications. Briefly, cells are fixed in 100 μl/well for 30min., followed by 100 μl/well permeabilization buffer with or withoutintracellular stain (depending on the staining panel used) for 30 min.Cells are twice washed with 200 μl 1× permeabilization buffer andcentrifuged (700×g, 3 min., 4° C.), followed by resuspension in PBS with2% FBS. 1×10⁶ events, excluding debris, are captured for each sampleusing a 10-channel LSR II cytometer (BD Biosciences) and analyzed usingFlowJo V.10.0.8 software. Data is represented as percent of tumor cells,with noted exceptions where represented as percent of parent population.Post-hoc t-test following ANOVA is used for statistical analysis betweenvehicle and treatment groups. The results are summarized in the Table 3.

TABLE 3 Compound B PD-L1 Vehicle Compound A (10F.9G2) Mean Mean Mean % ±p % ± p % ± p Population SEM value SEM value SEM value CD4+/Ki67+ 5.7 ±0.9 n.s. 7.6 ± 0.5 n.s. 8.8 ± 1.2 0.022 (% of CD4+) CD8+/Ki67+ 21.8 ±3.6  n.s. 23.1 ± 2.0  n.s. 24.1 ± 1.9  n.s. (% of CD8+) CD11b+ (% of 1.8± 0.2 n.s. 2.9 ± 0.2 0.002 2.1 ± 0.2 n.s. Tumor) CD11b+F4/80+ (% 0.62 ±0.11 n.s. 0.89 ± 0.15 — 0.67 ± 0.07 n.s. of Tumor) CD11c+ (% of 0.24 ±0.04 n.s. 0.42 ± 0.06 0.035 0.27 ± 0.03 n.s. Tumor) CD11b+Ly- 0.61 ±0.08 n.s. 1.12 ± 0.08 <0.001 0.76 ± 0.07 n.s. 6G+F4/80− (% of Tumor)Compound C Compound Compound PD-1 A + PD-L1 A + PD-1 (RMPI-14) (10F.9G2)(RMP1-14) Mean Mean Mean % ± p % ± p % ± p Population SEM value SEMvalue SEM value CD4+/Ki67+ 13.7 ± 2.0  <0.001 14.1 ± 1.2 <0.001 16.3 ±1.4  <0.001 (% of CD4+) CD8+/Ki67+ 32.1 ± 4.0  0.017 31.5 ± 1.2 0.00534.4 ± 2.5  0.002 (% of CD8+) CD11b+ 3.9 ± 0.3 <0.001 4.4 ± 0.5 <0.0014.2 ± 0.6 <0.001 (% of Tumor) CD11b+F4/80+ 1.87 ± 0.18 <0.001 1.75 ±0.28 <0.001 1.77 ± 0.33 <0.001 (% of Tumor) CD11c+ 0.31 ± 0.05 n.s. 0.46± 0.08 0.039 0.32 ± 0.07 n.s. (% of Tumor) CD11b+Ly- 0.99 ± 0.10 0.0031.29 ± 0.16 <0.001 1.29 ± 0.19 <0.001 6G+F4/80− (% of Tumor)

The data in Table 3 shows elevated inflammatory response as demonstratedby intra-tumoral CD4+Ki67+ (activated CD4+ T-cells), CD8+Ki67+(activated CD8+ T-cells), CD11b+ (myeloid cells), CD11b+F4/80+(macrophages), CD11c+ (Dendritic cells), and CD11b+Ly-6G+F4/80−(Neutrophils).

Gene Expression Analysis

For RNA isolation from the tumor, approximately 30 mg tissue is cut. RNAis extracted by RNeasy Protocol (version January 2002) using RNeasy96-well Column Plates (Qiagen, Valencia, Calif.; Cat #74182) and QiaVac96 vacuum manifold at 15 psi vacuum. Briefly, tissues are homogenized in800 μL Buffer-RLT containing 1% β-mercaptoethanol in 2 mL LysingMatrix-D® tubes (MP Biomedicals, Solon, Ohio; Cat #6913-500, Lot#6913-500-120156) in FP120 (ThermoFisher Scientific, Waltham, Mass.; Cat#6001-120) or FastPrep-24 (MP Biomedicals; Cat #116003500) at speed 6.0for two mixings each of 30 seconds. Tubes are centrifuged at 14,000revolutions per minute (RPM) for 30 minutes. Between 400-600 μL ofsupernatant is removed and mixed with equal volumes of 70% ethanol(Decon Labs, King of Prussia, Pa.; Cat #2401), and transferred onto96-well RNeasy Plate. Any potential contaminating DNA is removed byadditional DNase-I digestion (Qiagen, Cat #79254) on the column as persupplier's protocol. Total RNA is extracted in two 40 μL aliquots ofDNase/RNase-free water. The total RNA concentration is estimated usingNanodrop ND-1000 spectrophotometer by absorbance at 260 nM (ThermoScientific). Total RNA is stored at −80° C. until needed for cDNAsynthesis.

The High Capacity cDNA Reverse Transcription Kit (Applied Biosystems,Framingham, Mass.; Cat #4368813) is used to reverse transcribe 3 μgtotal RNA in a final volume of 100 μL in 96-Well PCR Plates (MolecularBioproducts, San Diego, Calif.; Cat #3419) using GeneAmp PCR System 9700(Applied Biosystems) with following parameters: 25° C. for 10 minutes,37° C. for 2 hours, and 4° C. for infinity. For long term storage, cDNAis stored at −30° C., and total RNA is stored at −80° C.

For Taqman procedure, 100 μL of cDNA is diluted with 200 μLRNase/DNase-free water in 96-Well Clear Optical Reaction Plate (AppliedBiosystems, Cat #4306737) and transferred to 2 mL RNase/DNase-free tubes(Ambion, Cat # AM12475). Taqman reaction is carried out using 2×Universal Buffer (Applied Biosystems, Cat #4318157) in a final volume of20 μL in 384-Well Clear Optical Reaction Plate (Applied Biosystems, Cat#4309849). Samples are dispensed with Tecan Automated PipettingWorkstation (Tecan US Inc., Durham, N.C.; Model: Freedom Evo-100 orEvo-150), and plates are read in ABI Prism 970011T SDS plate reader withfollowing protocol settings: 50° C. for 2 minutes, 95° C. for 10minutes, and 40 cycles at 95° C. for 15 seconds and 60° C. for 1 minute.The absolute C_(T) values are normalized based on a standard curve-basedmethod. All calculations are done in Microsoft Excel spreadsheettemplate, and % inhibition is calculated from control values.Statistical significance is analyzed on version 11 JMP Software (SAS,Cary, N.C.). The results are described in Table 4 as a fold changecompared to vehicle control. Statistically significant valuesof >1.5-fold (1.5×) are shown. No significant change in the expressionof genes examined in Compound A and PD-L1 alone treatment groups. Thedata demonstrates increased expression of genes associated withintra-tumoral inflammation and T-cell activation when Compound A iscombined with PD-L1 or PD1 antibody. All Taqman primers and probeslisted below were purchased from Applied Biosystems Inc. (AM) and theircatalogue number listed in the table as ABI # along with summary of theresults.

TABLE 4 PD-L1 + Com- PD1 + Gene pound A PD1 Compound A ABI # Ccl2 1.5xMm00441242_m1 Ccl3 2.4x Mm00441259_g1 Ccl4 2.4x Mm00443111_m1 Ccl5 6.5x4.1x 4.6x Mm01302427_m1 Infγ 4.6x 4.8x 4.4x Mm01168134_m1 Il2 6.6x 3.5x4.1x Mm00434256_m1 Il4 5.9x 2.6x 4.1x Mm00445259_m1 Il5 2.4xMm00439646_m1 Il10 2.0x Mm01288386_m1 Il12b 2.9x 2.1x Mm01288989_m1 Il1311.2x 5.0x 8.0x Mm00434204_m1 Tnfα 2.6x 2.2x Mm00443260_g1 Gzmb 2.0x2.3x 2.3x Mm00442834_m1 Tgfbr1 1.2x Mm00436964_m1 Tgfbr2 2.4xMm03024091_m1 Pd-l1 3.2x 2.7x 3.2x Mm00452054_m1 Pd-l2 11.0x 7.1x 6.8xMm00451734_m1 Pd-1 2.9x 3.5x Mm01285676_m1 Arg 2.1x Mm00477592_m1 iNos5.8x 4.7x 5.9x Mm00440502_m1 Ido 4.6x 3.5x 4.9x Mm00492590_m1 Icam 2.5x2.0x 1.9x Mm00516023_m1 Cd3e 3.2x Mm01179194_m1 Cd4 3.1x 2.6xMm00442754_m1 Cd8b1 3.2x 3.3x Mm00438116_m1 Cd20 8.9x Mm00545909_m1 Cd451.7x Mm01293577_m1 Cd68 1.6x 1.6x Mm03047343_m1 Cd69 1.8x 1.7xMm01183378_m1 Cd86 2.0x 1.6x Mm00444543_m1 Foxp3 2.8x 2.1x 2.4xMm00475162_m1 Icos 4.0x 2.7x 2.8x Mm00497600_m1 Lag3 2.9x 2.7xMm00493071_m1 Tim3 2.3x 2.2x 2.1x Mm00454540_m1 Tim4 2.8x 2.3xMm00724709_m1 Cd40l 4.3x 2.7x 2.8x Mm00441911_m1 Cd200r1 2.1x 1.8x 1.7xMm00491164_m1 Tnfsf4(Ox40l) 1.8x 2.0x Mm00437214_m1 Tnfsf18(Gitrl) 2.2x1.9x Mm00839222_m1 Tnfrsf4(Ox40) 2.2x 1.7x 1.6x Mm00442039_m1Tnfrsf18(Gitr) 2.5x 2.2x 2.0x Mm00437136_m1

We claim:
 1. A method of treating colorectal cancer, comprisingadministering to a patient in need of treatment of colorectal cancer aneffective amount of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof, and aneffective amount of a PD-1 or PD-L1 inhibitor selected frompembrolizumab, nivolumab, atezolizumab, durvalumab, and avelumab.
 2. Themethod of claim 1, wherein between 2.5 mg and 75 mg of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof isadministered.
 3. The method of claim 1, wherein between 10 mg and 50 mgof4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof isadministered.
 4. The method of claim 2, wherein4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof is administeredonce per day every other day over a five day period followed by two dayswithout administration (T.I.W.).
 5. The method of claim 1, whereinbetween 1 mg/kg and 3 mg/kg of the PD-1 or PD-L1 inhibitor isadministered.
 6. The method of claim 5, wherein the PD-1 or PD-L1inhibitor is administered once every 14 to 21 days.
 7. The method ofclaim 1, wherein between 2.5 mg and 75 mg of4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof isadministered, and between 1 mg/kg and 3 mg/kg of the PD-1 or PD-L1inhibitor is administered.
 8. The method of claim 7, wherein4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof is administeredonce per day every other day over a five day period followed by two dayswithout administration (T.I.W.), and the PD-1 or PD-L1 inhibitor isadministered once every 14 to 21 days.
 9. The method of claim 1, wherein4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide,or a pharmaceutically acceptable salt or hydrate thereof is administeredorally, and the PD-1 or PD-L1 inhibitor is administered intravenously.